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Arteritis, specifically Horton’s arteritis, also known as giant cell arteritis (GCA), is a type of systemic vasculitis that primarily affects medium and large-sized arteries. It commonly involves the branches of the carotid artery in elderly individuals, causing inflammation, thickening, and sometimes occlusion of the affected vessels. Early diagnosis and prompt treatment are crucial in preventing severe complications and managing symptoms effectively.
Clinical presentation plays a vital role in the diagnosis of arteritis in Horton. Patients typically complain of new-onset, unilateral, throbbing, and severe temporal headache, often described as the worst headache they have ever experienced. Accompanying symptoms can include scalp tenderness, jaw claudication (pain during chewing or talking), and visual disturbances such as transient visual loss, double vision, or amaurosis fugax. The headache is often persistent, lasts for hours, and may be worse in the morning. These symptoms, when combined with a patient’s age over 50, should raise suspicion for arteritis in Horton.
Due to the potential sight-threatening complications associated with arteritis in Horton, ophthalmological assessment is an essential part of the diagnostic workup. Ophthalmic evaluation may reveal abnormalities such as anterior ischemic optic neuropathy (AION), ocular ischemic syndrome, or central retinal artery occlusion (CRAO). Therefore, fundoscopy, visual acuity assessment, and visual field examination should be performed for all suspected cases.
Laboratory investigations can provide additional supportive evidence for the diagnosis. The erythrocyte sedimentation rate (ESR) is raised in the majority of Horton’s arteritis cases, with significantly elevated levels seen in over 80% of patients. The C-reactive protein (CRP) level is also typically elevated in arteritis. However, it is important to note that a normal CRP or ESR does not rule out the diagnosis entirely. A complete blood count may reveal anemia and thrombocytosis, which are other common findings associated with arteritis.
Temporal artery biopsy remains the gold standard for confirming the diagnosis of arteritis in Horton. It involves obtaining a small segment of the superficial temporal artery from the affected side and evaluating it histologically for the presence of giant cells, intimal hyperplasia, and inflammatory infiltrates. The procedure should be performed as early as possible after initiating corticosteroid therapy to increase diagnostic yield. However, it is important to note that a negative temporal artery biopsy does not rule out the diagnosis.
Other imaging studies, such as magnetic resonance imaging (MRI) or ultrasonography, may assist in visualizing the affected arteries and confirming the diagnosis. Typical findings on imaging include halo sign, increased arterial wall thickness, or stenosis of the affected arteries. These imaging modalities can be particularly useful in patients with negative or inconclusive biopsy results.
Prompt initiation of treatment is essential to prevent severe complications associated with arteritis in Horton. High-dose corticosteroids, such as prednisone, are the mainstay of treatment. The dosage is typically started at 40-60 mg per day and then gradually tapered down over several months. Other medications, such as methotrexate or tocilizumab, may be considered in steroid-dependent or refractory cases.
In conclusion, the diagnosis of arteritis in Horton requires a high index of suspicion based on the characteristic clinical features, supportive laboratory findings, and histological examination. Ophthalmological evaluation is crucial in detecting potential complications, and imaging studies can aid in confirming the diagnosis. Timely initiation of treatment with corticosteroids is vital in preventing severe complications and improving patient outcomes.
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